Changes over Time in COVID-19 Vaccination Inequalities in Eight Large U.S. Cities

The authors estimate the associations between community socioeconomic composition and changes in coronavirus disease 2019 (COVID-19) vaccination levels in eight large cities at three time points. In March, communities with high socioeconomic status (SES) had significantly higher vaccination rates than low-SES communities. Between March and April, low-SES communities had significantly lower changes in percentage vaccinated than high-SES communities. Between April and May, this difference was not significant. Thus, the large vaccination gap between communities during restricted vaccine eligibility did not narrow when eligibility opened up. The link between COVID-19 vaccination and community disadvantage may lead to a bifurcated recovery whereby advantaged communities move on from the pandemic more quickly while disadvantaged communities continue to suffer.

higher where low-SES individuals and people of color constitute more of the population (Wrigley-Field et al. 2021). Second, researchers have documented community inequalities in COVID-19 vaccinations by neighborhood disadvantage during early restricted vaccination eligibility periods (DiRago et al. 2022).
It is unclear, however, how much the recovery of disadvantaged neighborhoods has lagged after restricted vaccination eligibility periods. In this research, we examine whether existing gaps in vaccination rates between advantaged and disadvantaged neighborhoods closed as vaccine eligibility expanded. We examine this issue using vaccination data from eight cities over three time points between March 21 and May 3, 2021, capturing the onset of widespread eligibility. Our findings contribute to a rapidly growing body of literature examining inequities both due to the pandemic and as a result of the response and recovery phases.
In Figure 1A, we present adjusted predictions for percentage vaccinated in each period. In March, low-SES communities (23.01 percent; 95 percent confidence interval Note: Color-coded points show the estimated percentage, thin lines show the 95 percent confidence interval (CI), and thick lines show the 83.4 percent confidence interval. Alongside traditional 95 percent CIs, we show 83.4 percent CIs because these visually show significant differences at the p < .05 level with no overlap (Cumming 2009). We estimated three population-weighted linear regressions with each time point's vaccine rate as the dependent variable and all American Community Survey variables listed in the supplemental material as covariates. We then used the margins command in Stata/MP to estimate adjusted predictions at the means and adjusted predictions for four quartiles of socioeconomic status (SES) (Q1-Q4). We defined SES levels by setting all four SES variables to the same within-city quartiles within each scenario. We set other independent variables to within-city averages in each scenario.
In Figure 1B, we present adjusted predictions for the change in percentage vaccinated over time. Between March and April, low-SES communities (12.78 percent; 95 percent CI = 11.19 percent to 14.38 percent) had significantly lower change in percentage vaccinated than high-SES communities (16.92 percent; 95 percent CI = 15.38 percent to 18.45 percent). Between April and May, the difference between change in percentage vaccinated in low-SES communities (9.86 percent; 95 percent CI = 8.77 percent to 10.96 percent) and high-SES communities (8.82 percent; 95 percent CI = 7.39 percent to 10.25 percent) was not significant.
The percentage vaccinated in low-SES communities lagged that in high-SES communities in March, April, and May. Additionally, the large gap in percentage vaccinated between communities during the restricted vaccine eligibility period did not narrow when eligibility opened up in late April and early May. During the six weeks captured in our data, 64.5 million people received their first doses of vaccine, equal to 31.2 percent of all vaccinated individuals as of September 1, 2021. Thus, despite the rapid and widespread reach of vaccinations during this period, large inequalities persisted.
Our work suggests that a process of cumulative disadvantage at the community, and likely individual, level is unfolding because of the COVID-19 pandemic. The same communities that suffered the highest burdens of infection and mortality from COVID-19 before vaccines were available had lower levels of community vaccination during restricted vaccine eligibility and did not immediately close those gaps as eligibility opened up (Clouston, Natale, and Link 2021;Ransome et al. 2021). The link between COVID-19 vaccination and community disadvantage is concerning. Importantly, this continuing inequality may lead to a bifurcated recovery whereby advantaged communities move on from the pandemic more quickly while disadvantaged communities continue to suffer.
titled Audit Studies: Behind the Scenes with Theory, Method, and Nuance. His research appears in the American Journal of Sociology, Social Forces, Sociological Science, and elsewhere. His Web site is at www.stevenmichaelgaddis.com.
Colleen M. Carey is an assistant professor of economics and public policy at Cornell University. Her work focuses on the U.S. health care industry. Her primary line of research examines governmentmanaged markets for health insurance. A second line is focused on physician behavior, such as the role of financial relationships with drug firms or physician's response to demand shocks and price changes. She has written a number of articles examining the role of physicians in the U.S. opioid epidemic. She is a coeditor at the American Journal of Health Economics. She was previously a staff economist on the Council of Economic Advisers, a Robert Wood Johnson Scholar in Health Policy Research, and a visiting research scholar at Princeton University. She holds a PhD in economics from Johns Hopkins University and a BA from Yale University.
Nicholas V. DiRago is a doctoral candidate in the Department of Sociology and an affiliate of the California Center for Population Research at the University of California, Los Angeles. As an urban sociologist and social demographer, his research takes organizational and spatial approaches to housing, urban development, and neighborhood inequality in the United States. One set of his dissertation papers develops new methods of measuring organizational density and uses them to analyze how local organizations mediate socioeconomic outcomes for California social service recipients. Another dissertation paper evaluates the relationship between the organizational composition of low-income housing providers and the spatial distribution of subsidized housing across metropolitan areas. His research appears in Ethnic and Racial Studies, the Journal of Urban Health, and The Sociology of Housing (University of Chicago Press). He was awarded a T32 traineeship from the National Institutes of Health in 2020. His Web site is at www. dirago.me.